CDC Core
Section A: Health Status
1 Would you say that in general your health is:
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
    		•
    2 Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
    3 Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
    4 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
     
    CDC Core
    Section B: Health Care Access
    5 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?
    6 About how long has it been since you had health care coverage?
    7 Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
    8 Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health?
    9 About how long has it been since you last visited a doctor for a routine checkup?
     
    CDC Core
    Section C: Hypertension Awareness
    10 About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
    11 Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
    12 Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?
     
    CDC Core
    Section D: Cholesterol Awareness
    13 Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
    14 About how long has it been since you last had your blood cholesterol checked?
    15 Have you ever been told by a doctor or other health professional that your blood cholesterol is high?
     
    CDC Core
    Section E: Diabetes
    16 Have you ever been told by a doctor that you have diabetes?
     
    Access to CDC Optional Diabetes Module
     
    CDC Core
    Section F: Injury Control
    17 How often do you use seatbelts when you drive or ride in a car?
    18 How many children less than 18 years of age live in your household?
    19 What is the age of the oldest child in your household under the age of 15?
    20

    How often does the oldest child (of children under age 15) in your household use a...
    care safety seat [for child under age 5]
    seatbelt [for child 5 or older]
    ...when they ride in a car?
    21 Can you swim or tread water for 5 minutes in water that is over your head?
    22 Do you have a specific plan for how you would escape from your house or apartment in case of fire?
     
    CDC Core
    Section G: Tobacco Use
    23 Have you smoked at least 100 cigarettes in your entire life?
    24 Do you smoke cigarettes now?
    25 On the average, about how many cigarettes a day do you now smoke?
    26 During the past 12 months, have you quit smoking for 1 day or longer?
    27 Would you like to stop smoking?
    28 About how long has it been since you last smoked cigarettes regularly (that is, daily)?
     
    CDC Core
    Section H: Alcohol Consumption
    29 During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
    30 During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?
    31 A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. On the days when you drank, about how many drinks did you drink on the average?
    32 Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
    33 During the past month, how many times have you driven when you've had perhaps too much to drink?
    34 During the past month, how many times have you ridden with a driver who has had perhaps too much to drink?
     
    CDC Core
    Section I: Demographics
    35 What is your age?
    36 What is your race?
    37 Are you of Spanish or Hispanic origin?
    38 Are you:
     
    • Married
    • Divorced
    • Widowed
    • Separated
    • Never been married
    • A member of an unmarried couple
    39 What is the highest grade or year of school you completed?
    40 Are you currently:
     
    • Employed for wages
    • Self-employed
    • Out of work for more than 1 year
    • Out of work for less than 1 year
    • Homemaker
    • Student
    • Retired
    • Unable to work
    41 Which of the following categories best describes your annual household income from all sources?
    • Less than $10,000
    • $10,000 to less than $15,000
    • $15,000 to less than $20,000
    • $20,000 to less than $25,000
    • $25,000 to less than $35,000
    • $35,000 to less than $50,000
    • Over $50,000
    42 About how much do you weigh without shoes?
    43 About how tall are you without shoes?
    44 What county do you live in?
    45 Do you have more than one telephone number in your household?
    46 How many residential telephone numbers do you have?
    47 Indicate sex of respondent. Ask Only if Necessary
     
    CDC Core
    Section J: Women's Health
    48 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
    49 How long has it been since you had your last mammogram?
    50 Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
    51 A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical breast exam?
    52 How long has it been since your last breast exam?
    53 Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
    54 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
    55 How long has it been since you had your last Pap smear?
    56 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
    57 Have you had a hysterectomy (that is, an operation to remove the uterus/womb)?
    58 To your knowledge, are you now pregnant?
     
    CDC Core
    Section K: Immunization
    59 During the past 12 months, have you had a flu shot?
    60 Have you ever had a pneumonia vaccination?
     
    CDC Core
    Section L: Colorectal Cancer Screening
    61 A digital rectal exam is when a doctor or other health professional inserts a finger in the rectum to check for cancer and other health problems. Have you ever had this exam?
    62 When did you have your last digital rectal exam?
    63 A proctoscopic exam is when a tube is inserted in the rectum to check for cancer and other health problems. Have you ever had this exam?
    64 When did you have your last proctoscopic exam?
     
    CDC Core
    Section M: AIDS Knowledge and Testing
    65 Can you tell by looking at a person if he or she has the AIDS virus?
    66 Would you be willing to work next to or near a person who you know is infected with the AIDS virus?
    67 If you had a child in school, would you allow him or her to be in the same classroom with another child who is infected with the AIDS virus?
    66 If you had a teenager who was sexually active, would you encourage him or her to use a condom?
    67 What are your chances of getting the AIDS virus?
    68 In the past year, have your chances of getting the AIDS virus increased, decreased, or stayed the same?
    69 Some people use condoms to keep from getting infected with HIV through sexual activity. How effective do you think a properly used condom is for this purpose?
    70 To your knowledge is there medical treatment available that may help a person who is infected with the AIDS virus live longer?
    71 What are your chances of getting the AIDS virus?
    72 In the past five years (that is, since 1988), have your chances of getting the AIDS virus increased, decreased, or stayed the same?
    73 Except for donating or giving blood, have you ever had your blood tested for the AIDS virus infection?
    74 When was your last test?
    75 What was the main reason you had your last AIDS blood test?
    76 Where did you have your last blood test for the AIDS virus?
    77 If you received the results of your last test, did you receive counseling or talk with a health care professional about how to lower your chances of becoming infected with the AIDS virus or how to avoid passing it on to another person?
     
    CDC Optional
    Module 1: Smokeless Tobacco Use
    1 Have you ever used or tried any smokeless tobacco products such as
    chewing tobacco or snuff?
    2 Do you currently use any smokeless tobacco products such as
    chewing tobacco or snuff?
     
    CDC Optional
    Module 4: Fruits and Vegetables
    1 How often do you drink fruit juices such as orange, grapefruit, or tomato?
    2 Not counting juice, how often do you eat fruit?
    3 How often do you eat green salad?
    4 How often do you eat potatoes (not including french fries, fried potatoes, or potato chips)?
    5 How often do you eat carrots?
    6 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
     
    CDC Optional
    Module 5: Diabetes
    1 How old were you when you were told you have diabetes?
    2 Are you now taking insulin?
    3 In general, how would you rate your vision when wearing glasses or contacts if needed?
    4 How often do you have trouble telling the difference between a one dollar bill and a five dollar bill?
    5 While stopped in a vehicle at a traffic light, how often do you have trouble reading the license plate on the car in front of you?
     
    CDC Optional
    Module 6: Exercise
    1 During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
    2 What type of physical activity or exercise did you spend the most time doing during the past month?
    3 How far did you usually walk/run/jog/swim?
    4 How many times per week or per month did you take part in this activity during the past month?
    5 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
    6 Was there another physical activity or exercise that you participated in during the last month?
    7 What other type of physical activity gave you the next most exercise during the past month?
    8 How far did you usually walk/run/jog/swim?
    9 How many times per week or per month did you take part in this activity?
    10 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
     
    CDC Optional
    Module 7: Weight Control
    1 Are you now trying to lose weight?
    2 Are you eating fewer calories to lose weight?
    3 Have you increased your physical activity to lose weight?
     
    CDC Optional Module
    Module 8: Activity Limitations
      Section A: Ages 18-64
    1 What were you doing MOST of the past 12 months?
    2 Does any impairment or health problem NOW keep you from working at a job or business?
    3 Are you limited in the kind or amount of work you can do because of any impairment or health problem?
    4 Does any impairment or health problem NOW keep you from doing any housework at all?
    5 Are you limited in the kind or amount of housework you can do because of any impairment or health problem?
    6 Does any impairment or health problem keep you from working at a job or business?
    7 Are you limited in the kind or amount of work you could do because of any impairment or health problem?
    8 Are you limited in any way in any activities because of any impairment or health problem?
    9 Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
    10 Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
      Section B: Ages 65 or older
    11 Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
    12 Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
    13 Are you limited in any way in any activities because of an impairment or health problem?
     
    State-Added
    State-Added Module: Smoking in the Work Place
    1 Do you work outside the home?
    2 Which of the following best describes the policy about smoking at your work place?